Money, charity, the NHS and the case of Mr R

There was snow on the ground, and big flakes in the air this morning as I boarded the bus to Kennington. It is the 11th day of Christmas, and the first day back at work for many people in the country. There are quite a few cases beginning today in the Fitness to Practice rooms, so many indeed that the HPC was renting some from its neighbour the Evangelical Alliance. As I walked through the doors I was greeted by a flat screen tv display telling me 'Kind words are like honey, sweet to the taste and good for your health'. Proverbs 16 24

Kind words can cost you your reputation as an HPC health professional, or at least, a kind act can if today's case is a typical example.

The allegation in this case is a short one: "that Mr R provided private speech and language therapy treatment to [a client] whilst also treating them on NHS caseload at [a PCT]". When I popped my head round the door to see if the business had begun the Chair was quizzing the Barrister on the use of the word 'them'.

The writer of the allegation had been at pains to avoid bringing the patient into view. For this reason she had avoided the word 'him' and used 'them' in its place. This switch from single to plural had created the impression that Mr R was in the habit of taking his patients into his private practice. The point clarified that only one patient was in question, and that language might be used for other purposes than simply stating facts.

There was only one witness in today's case: Ms B. She had been employed to replace Mr R when he resigned at the end of Sabbatical. They had never met. Mr R had seen his patient for the standard 5 sessions and was closing the case. However, he had not filled in the last form before going off on leave. So, when Ms B turned up she acquired a case that was all but closed, needing only one final act to make it so. She visited the patient at home to make her assessment, and agreed to close the case.

In this morning's part of the hearing a lot of context and detail was revealed. For example, it turns out that the patient is a young man, probably in his twenties. He is married, but still lives at home with his mum and dad whose culture and religion happens to be the same as Mr R. They all speak the same two home languages as well as English. In the detail of the discussions this morning, I understood that mum and dad were doing their best to 'normalise' their Down Syndrome son, and had high hopes that the 'articulation process' of the speech and language therapy would make him just like anyone else. In the meantime dad often spoke on his behalf, jumping in to answer questions and give opinions instead of leaving a space for his son to struggle in. Mr R put it like this - he said there was a lot of energy in the room when the parents were present. In fact, as the case unfolded, Mr R said that his own intervention was less to do with administering the standard procedure and more focused on working with the family to create space in which the young man could find his own way to communicate.

By all accounts the work was successful but the STAP [the South Tyneside Assessment of Phonology] showed that further standardised treatment was unlikely to match target outcomes. The patient and his parents all wanted to carry on with the work, and all agreed that Mr R was the man to do it. The parents were particularly keen, and asked Mr R several times if he would carry on - never mind the rule about 5 sessions, they would pay they were so pleased with the results.

When Ms Betts turned up to make her assessment, the patient's parents let slip that Mr R had done some work with their son outside the domain of the NHS. As soon as they had said this they realised they had dumped their man in trouble and clammed up. But Ms B was not to be deflected. She wanted to know how often this had happened and how much he had been paid. The more she asked the less they said, the message had been instantly transmitted! Something unspeakable had happened, and now the family began to worry that they had caused Mr R to be sacked.

In a way they were right. They had not reckoned on Ms B clinging so tenaciously to the rule book, nor indeed that such a rule book had in fact been written, and they certainly never imagined anything like the HPC who would use such a book to purge the profession of any imaginary stain.

As it turned out Mr R did see this family about four more times outside the NHS protocol. He accepted about £6 from them to avoid the embarrassment that was created through his refusal to accept a proper fee. Today, 2 or 3 years later he says he would definitely never do that again.

Quite right; if he does work in private, he should participate directly in the symbolic exchange that regulates it. He might negotiate a proper price for himself, refer the case to a colleague in private practice, or perhaps he could channel the money to a charity.

No! None of these ideas were considered. Mr R now knows not to accept private work because it would catch him in this dreadful process that might ultimately prevent him from working. For if he is struck off (and that is the HPCs intention - 'a clear case of misconduct'), then he will be legally prevented from practice. In future, he will not try to help a family in need, he will attend only to the requirements of his cv.

From where I sat in this proceeding, I would say there's a very strong possibility that money is a tabu topic in the NHS and forecloses any sensible discussion about working effectively with patients. It certainly muddied the discussion at the HPC. (Was he accused because he took money - sub-text because was greedy? Or because he gave charity - sub-text that he was naive? The prosecuting agent didn't mind which, so long as she nailed him with one.) What was quite clear from this morning's discussion was that the family made direct and repeated demands for treatment that the NHS protocol ruled out. Mr R however, could see that something less rigid and more responsive could and would have a good effect. For goodness sake! What on earth is wrong with that? That Mr R will never do that again is, well, it's a shame. And if The Public conjured up colludes with this ruse then we are in bigger trouble than I had thought.

It was said several times by Ms B that a professional must act ethically to protect himself from suspicion. This puts a curious twist on the question "who is being protected by the HPC, and from what?" Listening to Ms B it seems that 'the public' that is protected is the one that belongs to a profession. What the HPC is protecting this public from is the accusation from an ill-informed mob who might otherwise point the finger of suspicion. There are two kinds of public here. One is being protected from the truth, the other is being protected from any possible accusation of suspicion.

Poor show. Doubly so, for in another time or another place it would be quite normal to deal with this question in an ordinary conversation between people (supervision? seminar? collegiate conversation? quiet personal reflection?), or even just getting on with the job and accepting a fee for it. What we have instead is an elaborate construction of something approaching a kangaroo court dressed up as respectable profession.